Sunday, September 25, 2011

READY… STEADY… SURGERY

Things you need to know about preparing for surgery

        I'm back. So you missed me.  Not as much as I missed writing on my blog though.  For the past few weeks, the Philippine Hip and Knee Society (PHKS) convention has been foremost in my activities, being part of the Organizing Committee and of the team of speakers.  There is so much pressure involved in researching and preparing a scholarly lecture before former mentors and colleagues in the profession.  I had to pay attention to every detail, write and re-write my manuscript and think of all the possible post-lecture questions they will throw at me.  

      But on the other hand, it was an honor and privilege to speak before my esteemed colleagues.  I’d like to extend my gratitude to Dr. Greg Azores, the incumbent President of the PHKS, and Dr. Paul San Pedro, my mentor at the Philippine Orthopedic Center, for inviting me to join the society and share my knowledge as one of the speakers.

Photos courtesy of Dr. Iggy Agbayani





         Now, since the topic of my lecture there was how to evaluate and prepare patients undergoing total joint replacement, I realized that some points of that lecture might interest you, especially patients considering surgery.

        You may be trying to avoid surgery at all costs, but there are times when surgery becomes a necessity. So let me illustrate the pre-operative procedures for most surgical patients.  

         Here’s the story of one of my patients.

        My patient had a knee condition that had gone from bad to worse.  Initially, I diagnosed her with knee osteoarthritis about 2 years ago.  She could hardly walk then and was already confined to a wheelchair.  I informed her that whereas we would be trying other modes of treatment at that time (medicines, pain control, and therapy) she would eventually need to undergo total knee replacement in the future.  Physicians use the phrase “lost to follow up” when patients stop coming for regular consultations.  So after a few consultations, perhaps due to lessened pain and discomfort, this patient was eventually lost to follow up.  

       Last week, lo and behold, my lost patient was found… on my patient list for the day.  Her pain returned and had gotten worse.  After some knee injections for pain control, her family told me that, while they understand the need for surgery, they were buying a little more time because of the expenses involved.  “Yes, of course. No problem,” I told them.  I made a careful evaluation of her knee again, including the hips and spine.  Repeat xrays confirmed worsening of the condition. 

       After a few weeks, they called my clinic to inform me that the effect of the injections had waned and their family decided to have their mother operated on for a total knee replacement.

Pre-op and Clearance  

    First, we discussed, in general terms, what to expect during hospitalization, the length of confinement, the recovery period, etc. Then we decided on the exact date of surgery.  

     The patient needed to get blood exams, a chest xray and an electrocardiogram (ECG) test.  Dental check-up and urine test was also advised.  The possibility of blood transfusion was discussed with the patient and so they agreed to find blood donors. 

       They were seen by a medical colleague known as an internist (a doctor who specializes in Internal Medicine) a few times before surgery with the understanding that he will be giving the “medical clearance” to undergo surgery.  Her general medical condition and allergies were documented. These procedures needed to be done since we wanted the patient to be at the peak of health during surgery and to determine if, in consideration of her age and medical problems, she can still tolerate the procedure safely.  The medications she was taking were also reviewed, and the meds that can affect bleeding during surgery, like aspirin, were stopped.
       This assessment gave us the opportunity to weigh the benefits versus the risks of undergoing total knee replacement.  She was eventually cleared to undergo surgery by the internist.

The Day before surgery

        They arrived at the hospital in the afternoon, the day before the scheduled surgery, carrying with them the admitting orders I gave them, as well as the xray plates taken at the clinic.  It is important to bring the xrays as we need the plates during surgery to make certain measurements. 

         At the admitting section, they filled out some paperwork and were soon going through all the prep questions:  “Your name please?" "Date of birth?" "When are you having the surgery done?"  "Which knee?"  These were all noted in the patient's hospital chart.

         Before being taken to the third floor room reserved for them,  they told me the thing that took extra time was getting the IV line in.  According the son, this was no surprise to them, as many times in the past, this was a challenge for nurses. A second nurse eventually came and managed to get the line in at the first try.  She was ready to go to the room.

         Nighttime came and another important member of the surgical team, the anesthesiologist, came to their room.  After a pleasant exchange of “hi's and hello's”, the anesthesiologist explained the different types of anesthesia to the family, with their corresponding risks and benefits.  They eventually agreed that regional anesthesia (a type of anesthesia where only the lower part of the body is anesthetized, and the patient is sedated), would be used. Consent was signed in the presence of the relatives.  The patient was reminded not to eat and drink anything past midnight.

The Day of the Surgery

      The OR nurse came in their hospital room at around 6 in the morning (surgery scheduled at 7 AM) and said it was time for hugs & kisses.  The eldest daughter told her mother she would see her later in the recovery room and went straight to the hospital chapel.  Her son-in-law arrived and figured it was time for some snack while they had a chance.  
  
        Antibiotics were injected through her IV line prior to the patient being put into sleep. She eventually underwent total knee replacement surgery.  During surgery, no untoward incident happened.  After about two (2) hours, the patient was wheeled to the recovery room.

       In my patient’s own words “The experience was simple. The fear was only in the beginning. The joy you’ll feel when you awake from surgery, and realize you’re on your way to being healed is amazing!!!”

Surgery is risky, but it is a calculated risk.   
“The surgeon does the calculating, the patient takes the risk!”


         Not all surgeries are successful.  Not all surgeries proceed without complications or difficulties for the surgeon.  With total joint replacement, however, there is a very high rate of success.  Literature puts it at 98%.  But a vital part to this success is, for the surgeon, proper preparation and planning.  Proper evaluation and preparation helps us weigh the benefits versus the risks of the surgery, and clear up some doubts with the patient. 

       For the patient, following pre-op guidelines, and knowing what to expect before and during surgery, can make a big difference in your recovery and success.  A well-informed and motivated patient makes a difference.



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